Tag Archives: politics

Some conservatives are unwilling to accept the status quo. They are pushing back against congressional inertia and conservative fatalism as they urge Congress to roll back the Obamacare regime.

I was disgusted last week speaking with a friend who is a very powerful strategist in the Democratic Party. She agreed with me when I suggested to her that the Democrats would Never sign off on either an immigration or health care plan until after the midterm election. I sensed this after the President signed an Executive Order reversing the separation of illegal immigrant children from their illegal parents as the Democrats, especially Ms. Pelosi and Mr. Schummer asked him to “pen”.

How can we make any progress at all when there is no cooperation between the parties and the administration? I am truly frustrated and wonder when we all are going to wake up and make these Senators and Representatives to “do their job”! They all only care about their own reelection models…. and impeaching the President. How have we sunk so low, so far??

Congress is still wading through the swampy waters of Obamacare. Congressional Republicans, who ran against Obamacare through four election cycles, have spent most of the past year running away from it. But they are finding the law hard to escape.

Democrats who once shied away from Obamacare now can’t stop talking about it. They are blaming Republicans for the next round of premium increases that will become finalized in the weeks leading up to the November elections.

Republicans will justifiably respond that Obamacare is a mess they didn’t make. Voters may nevertheless hold them accountable for not cleaning up that mess, despite years of campaign promises.

Congress should keep those promises, according to a group of conservative policy analysts, state-based think tanks, grassroots organizations, and GOP governors and state legislators. Tuesday, a group of them announced support for the Health Care Choices Act, a proposal that would repeal Obamacare entitlements and replace them with grants to states to finance consumer-centered reform.

The plan is innovative and bold. The ill-fated bills Congress considered last year kept the federal structure of Obamacare with relatively minor modifications. For example, those proposals modified the federal tax credits that are at Obamacare’s core; the Health Care Choices Act would repeal them. And while last year’s bills would have reduced federal spending on Medicaid coverage of able-bodied adults, the Health Care Choices Act would scuttle the Medicaid expansion policy entirely.

The proposal resembles the successful welfare reform of the 1990s, which repealed the individual entitlement to cash benefits and replaced it with grants to states to assist the needy. The Health Care Choices Act does the same thing with health care, but on a much grander scale. It would repeal an open-ended federal entitlement program expected to cost $1.6 trillion over the next decade and replace it with a block grant. It is welfare reform on steroids.

Block grants are not blank checks. Like welfare reform, which required states to implement policies to encourage work and reduce dependency, the Health Care Choices Act would require states to pursue two important goals: reducing costs and increasing health care choices.

States would be required to spend a portion of their federal allotments on meeting the medical needs of the sick without saddling the healthy with exorbitant premiums. Other stipulations would prevent states from using the money to expand Medicaid or to warehouse the poor in state-contracted managed care plans. States would have to provide low-income people assisted through the through the block grant, as well as Medicaid and State Child Health Insurance (CHIP) recipients, the option of applying the value of their assistance to the plan of their choice. Think of it as school choice for health care.

The new money would be provided through the CHIP statute, which, unlike Obamacare, includes permanent restrictions on the use of funds for abortion. Within those broad guidelines, states would design their own programs, determining who is eligible for assistance and what they’re eligible for. They would be released from Obamacare regulations on essential health benefits, age-related premium variation, and the requirement that insurers enroll the sick and healthy in the same insurance pools. Repealing these regulations would allow states to repair or ameliorate much of the market dislocation Obamacare produced.

In short, the Health Care Choices Act would dismantle two of Obamacare’s pillars and weaken the third: Obamacare’s individual entitlement would be abolished, the employer mandate (like the individual mandate) would be repealed, and federal insurance rules would be diluted.

Some conservatives look at the proposal’s health care reform donut and complain about the hole. They have particularly faulted the plan for not repealing Obamacare’s pre-existing condition rules.

A Republican reaction to last week’s Justice Department motion in a lawsuit that seeks to invalidate these rules is instructive. Democrats attacked the Trump administration – and Congressional Republicans – for opposing pre-existing condition protections.

To stanch the political bleeding, Senate Majority Leader Mitch McConnell declared, “Everybody I know in the Senate – everybody – is in favor of maintaining coverage for pre-existing conditions.”

McConnell’s colleagues pointedly did not race to the microphones to distance themselves from their leader. Nor are scores of House and Senate conservative incumbents campaigning on a promise to repeal the popular pre-existing condition requirements.

The message is clear: repealing that requirement does not enjoy anything like majority support even in a GOP Congress. For some conservatives, that is reason enough to leave Obamacare in place. If Congress can’t pass a perfect bill, they argue, then it shouldn’t pass anything at all.

A growing cadre of conservatives is unwilling to accept the status quo. They are pushing back against congressional inertia and conservative fatalism as they urge Congress to roll back an Obamacare regime that continues to raise costs and constrict health care choices.

They view the Health Care Choices Act’s repeal of Obamacare’s entitlements and devolution of power from Washington to the states not as the final word on health care reform, but as an essential component of a broader effort. Expanding health savings accounts is part of that effort. Promoting innovative approaches like health-sharing ministries and direct primary care is another. Trump administration regulatory proposals to allow small businesses and independent contractors form health insurance purchasing groups across state lines also are part of it, as is its plan to expand the sale and renewal of short-term, limited duration policies.

Conservatives who back the Health Care Choices Act prefer real progress to theoretical perfection and the inaction it induces. They also argue that it is politically better for Republicans to confront Obamacare than to be blamed for its failures.

Republicans are stuck in a Nash equilibrium on Obamacare repeal. Conservative firebrands, Republican moderates, and congressional leadership – each for very different reasons – are content to make Obamacare repeal the new balanced budget, something they talk about to mine money and votes from their base, but never seriously pursue.

The millions of families and thousands of small businesses suffering under Obamacare deserve better.

Obamacare Faces New Life-threatening Conditions

Opponents of the Affordable Care Act have been busy. In the midst of several headline-making events on other issues, the Trump administration has instigated two major efforts to effectively do what Congress could not do earlier this year — repeal Obamacare.

The result is a laundry list of warnings for all health care consumers, not just those who buy insurance on the ACA exchanges. Here’s a closer look at the latest changes to the health insurance marketplace:

Expanding association health plans

The administration issued new rules on Tuesday that expand the use of what’s known as association health plans. They allow small businesses and self-employed individuals to buy health insurance collectively through what’s loosely defined as an industry association. By pooling together, members can buy insurance for less expensive group rates, the way employees of large corporations do.

Association plans have been around for a long time, but under the ACA they were restricted. The new rules loosen some of these restrictions and expand the reach of these plans. At the same time, these plans are exempt from many of the protections under the ACA, including coverage of the 10 essential health benefits such as maternity and mental health services, hospitalization and prescription drugs.

In addition, the new rules allow association plans to sell insurance across state lines. States regulate health insurers, and for the most part, insurers must adhere to each state’s regulations for the consumers they serve in those states. But under the new rules, association plans can choose which state they want as their regulatory jurisdiction. That means they could conceivably choose a loosely regulated state as their home base.

Association plans have seen their share of scandals in the past, largely due to this state regulatory confusion.

The new rules aren’t a surprise. The Trump administration has been calling for the expansion of association health plans as a way of offering more options outside of Obamacare and a way for small businesses and individuals to have access to more affordable group insurance.

But advocates worry that the move is a return to the bad old days before insurers had to adhere to standard regulations that protected consumers from paying insurance premiums, only to find coverage wasn’t there when they needed it.

“The new rule will allow groups of businesses to band together to buy insurance across state lines, which will be bad for small firms and their employees because it will lead to higher premiums, unbalanced risk pools and lower-quality insurance,” said John Arensmeyer, founder, and CEO of Small Business Majority.

In addition, the provision may encourage a new batch of healthier people who can get by with skimpier coverage to sign up for association plans instead of the ACA exchange plans. That could leave more sick people in the exchanges without the benefit of younger, healthier people balancing the risk pool. According to the Congressional Budget Office, 6 million people are expected to enroll in expanded association health plans.

If you’re considering one of these plans, many of which are expected to be available in September just before the 2019 ACA open-enrollment period, be sure to read everything you can get your hands about the plan as carefully as you can. You’ll want to be sure you understand any limitations in coverage so you can determine if the plan is right for you.

A threat to preexisting condition coverage — and more

Tuesday’s announcement comes on the heels of another potentially devastating blow to the ACA. Earlier this month the Justice Department announced it would not defend the law against a lawsuit brought by the attorneys general of Texas and 19 other states.

The suit claims that because the newly enacted tax law eliminates penalties associated with the individual mandate, the ACA requirement that most Americans carry health insurance is no longer constitutional. In addition, the suit contends that consumer insurance protections under the law also aren’t valid.

Since then an outcry has been heard from health care advocates, insurers, congressional Republicans and most recently a group of bipartisan governors from nine states. The protest is focused on the provision in the ACA that requires insurers to provide equal coverage and the same premium rates to people with pre-existing conditions as they provide to people without previous health problems.

The requirement applies to all insurers, not just those in the exchanges, and polls show most Americans — including many who don’t support Obamacare overall — want to preserve it. Even Senate Majority leader Mitch McConnell famously said, “Everybody I know in the Senate, everybody, is in favor of maintaining coverage for preexisting conditions.”

Still, the Texas court case would potentially eliminate many more ACA provisions, including the premium subsidies so many exchange customers rely on, essential health benefits and Medicaid expansion, said Eliot Fishman, senior director of health policy at Families USA. That said, Fishman believes the court case will take time, so consumers who are planning on signing up for exchange coverage for 2019 at the end of this year should not be dissuaded from doing so.

Health warning-Obamacare is in legal peril once again! Many legal scholars are dismissing a new case. Don’t listen to them.

Noah Feldman wrote that one shouldn’t turn your back. Could key portions of the Affordable Care Act be declared unconstitutional – years after the Supreme Court upheld them? The Trump administration’s Department of Justice has just filed a brief saying so in a suit by several states that aims to take down the whole program.

Most mainstream legal commentators think the government’s arguments are unconvincing. But it’s crucial to remember that this was exactly the reaction of the same set of people in 2010 when the original argument was made against the individual mandate by libertarian law professor Randy Barnett. Just two years later, five justices of the Supreme Court embraced Barnett’s argument.

Given the excitement for judicial activism building among conservatives, the Trump administration may have more than a 50 percent chance of success.

Just in case you haven’t thought much about the individual mandate and the Constitution in the last six years, let me provide an update and a brief refresher. The update is that, in 2017, Congress passed the Tax Cuts and Jobs Act. In the law, Congress repealed the tax penalty associated with the individual mandate that everyone has health insurance.

In other words, the ACA still says you have to have insurance. But if you don’t, nothing happens to you. You may remember that the Obama team was worried about the interaction between the individual mandate and the popular ACA provisions that say insurance companies can’t refuse to cover anybody because of pre-existing conditions and can’t charge you more if you are already sick.

The theory went something like this: If you aren’t compelled to buy insurance when you’re healthy, but you’re allowed to buy it when you find out you are sick, then only sick people would buy health insurance. That, in turn, would create a “death spiral” for insurance under the ACA, as insurance costs went up.

Crucially, President Barack Obama’s Department of Justice relied on this argument in trying to convince the Supreme Court to uphold the individual mandate. This death spiral doesn’t seem to have happened yet, however.

Now comes the new constitutional challenge to the ACA, filed by a group of states led by Texas. Their argument begins with the fact that, when the Supreme Court upheld the individual mandate, it did so in a very strange way. The five conservative justices all agreed that, under the commerce clause of the Constitution, Congress did not have the authority to make people buy insurance.

Their reasoning was borrowed from Prof. Barnett, who had proposed in his article that while the Congress has the power to regulate existing commercial activities, it can’t force people to undertake a commercial activity they are not already engaged in. This was the famous broccoli hypothetical: the conservatives argued that the commerce clause wouldn’t allow Congress to pass a law requiring everyone to buy and eat broccoli, even though Congress could lawfully regulate broccoli prices.

Despite this conclusion about the commerce clause, however, Chief Justice John Roberts joined the four liberals to uphold the individual mandate on the ground that it was a tax and therefore fell within Congress’s separate taxing power. The other four conservatives were clearly frustrated with Roberts, but his vote carried the day.

The states are now arguing that once Congress repealed the tax penalty for the individual mandate in the 2017 law, no more constitutional authority exists for Congress to keep the individual mandate in place. The Supreme Court already excludes the commerce clause, and now the tax rationale is gone. Trump’s Department of Justice has agreed with this claim.

The states say that without the individual mandate, the whole ACA should be struck down as unconstitutional. Trump’s Justice Department didn’t go quite that far. But it did say that the ACA provisions on pre-existing conditions are so linked to the individual mandate that it should now be struck down.

Legal observers are pretty upset about this — but not all for the reason you’d think. Some are focused on the strange circumstance that Justice is arguing that the law is unconstitutional. It’s not supposed to work that way. The executive branch is supposed to argue in favor of the constitutionality of laws currently on the books.

That’s bad, without a doubt. But it seems less worrisome than the possibility that courts, including the Supreme Court, might actually adopt the Trump administration’s view and strike down the ACA provisions on pre-existing conditions.

Legally, I don’t think that would be the right decision. I don’t think that the repeal of the penalty means that the no-penalty individual mandate is necessarily unconstitutional, since there is no sanction for violating it, so it isn’t really much of a law at all.

And even if the no-penalty mandate were unconstitutional, it doesn’t follow that the mandatory coverage provisions need to go. They are logically separate from the individual mandate. The mandate may have been thought been necessary to make those provisions work in practice, but it turns out that, so far at least, they are operating without it, and the death spiral hasn’t happened.

But it is entirely possible that five justices would follow the chain of formal logic laid out by the states and adopted by the Justice Department. The best argument in favor of that position is that the Obama Department of Justice told the Supreme Court years back that these provisions were interlinked – “inseverable” in legal jargon.

There is, therefore, a real and indeed significant chance that the most popular part of the ACA could be struck down. You may have thought that the whole ACA-and the-courts topic was over. But as it turns out, it keeps coming back, like a figure from a horror movie. Don’t turn your back.

And look at all of the campaign “idiots” who are experts on health care and declare that their State will have better healthcare by adopting Medicare for All. Don’t they know that Medicare is a Federal program that States can’t themselves change? And how are they going to pay for it if the prediction that Medicare and Social Security programs will be out of money by 2026-2034?

California’s next governor faces a long list of challenges, from housing and health care to immigration. It seems like the upcoming mid-term elections that healthcare will be a dominant item in the debates. As Jonathan Cooper wrote, no topic has dominated California’s governor race like President Donald Trump including what he and the GOP are attempting to do with Obamacare. The Republicans want to be like him; the Democrats want to oppose him. But whoever wins will face a long list of challenges from housing and homelessness to health care. For example, all the Democrats say they support, at least in concept, “single-payer” health care — the idea that the government should pay for health coverage for everyone in the state, instead of the complex mix of employers, unions, individuals, Medicare and Medicaid that reigns today. But that didn’t stop it from being a major sticking point between them. Newsom was an enthusiastic supporter of a bill sponsored by the California Nurses Association that would implement a “single-payer” health care system. But it lacked key details, most notably a plan to cover the $400 billion cost. Chiang and Villaraigosa accuse Newsom of misleading voters with unattainable promises. Villaraigosa called it “snake oil.” For his part, Newsom calls his rivals “can’t-do Democrats” too fixated on the challenges of single-payer health care. Allen and Cox oppose single-payer health care.

Here are more of the specifics of the debates and is it really a single payer system or universal health care?

When Gavin Newsom campaigns on his support for a California single-payer healthcare system, he’s talking about more than the virtues of universal care. He’s trying to sell himself as a bold visionary.

When Antonio Villaraigosa warns of the financial calamity that awaits if the state adopts single payer, he’s trying to send a different message — that he’s a fiscally responsible realist who won’t make promises he can’t keep.

The debate over single payer in California’s race for governor reaches beyond how best to cure the inadequacies of health care in the state. It’s a political marker for the top Democratic candidates trying to woo different factions of their divided party and has emerged as the biggest policy flashpoint in the campaign.

“Single-payer health care has become a clear litmus test. If you support it, you’re a pure progressive. If you’re opposed to it, you’re a pragmatist,” UC San Diego political scientist Thad Kousser said. “It’s more of a declaration than a policy promise because this is never going to happen, certainly during the Trump presidency.”

But Newsom has promised to pursue a state-supported single-payer health care system if he’s elected in November. And fellow Democratic candidate Delaine Eastin, a former state superintendent of public instruction, also declared herself all-in on the concept. Both say California should lead the way but have been criticized by their rivals for failing to provide a concrete plan to fund such a program or overcome the many obstacles it would face.

Depending on who becomes the next governor, every Californian’s well being and bank account could potentially undergo a revolutionary change. With the June 5 primary just two months away, Newsom remains the clear front-runner.

Coverage of California politics:

“My opponents call it ‘snake oil,'” Newsom said at the California Democratic Party convention in February, a reference to Villaraigosa’s oft-used criticism of the lieutenant governor’s support for the plan. “I call it single payer. It’s about access. It’s about affordability. And it’s about time. If these can’t-do Democrats were in charge, we wouldn’t have had Social Security or Medicare.”

Villaraigosa dismisses Newsom’s campaign promise as a hollow attempt to entice the left. He said the system Newsom supports would require all Californians on Medicare to give it up in favor of a new, unproven state healthcare system — a declaration meant to rile up the 5.6 million residents covered by the popular federal program.

“Newsom calls any attempt to demand details of his $200-billion tax increase and plan to force seniors off of Medicare as ‘defeatist,'” Villaraigosa said recently. “I call refusing to say how you will successfully persuade Californians to more than double their taxes while taking away their Medicare simply deceptive.”

State Treasurer John Chiang, the other major Democrat in the running, has also urged caution. Instead of transforming healthcare in California in one fell swoop, the state should implement single payer bit-by-bit to ensure that it’s affordable and effective, he said.

“I support single-payer, but we have to be truthful here,” Chaing said during a fall Democratic debate in San Francisco. “How many of you want to pay an additional 90% in taxes? … Let’s scale up, see what revenues we have because we can’t cover everything.”

In Washington, former presidential candidate Sen. Bernie Sanders (I-Vt.) is leading a push for a plan that would, in essence, expand Medicare to provide healthcare to all Americans., For now, it’s little more than a political mirage — the Trump administration and congressional Republicans have been trying to repeal, not expand, government healthcare coverage provided under the Affordable Care Act.

With federal action unlikely, the California Legislature debated in 2017 whether to implement a state-sponsored single-payer system. The legislation, Senate Bill 562, was shelved in the Assembly over concerns about the cost and the lack of a comprehensive plan of how to pay for and implement such a massive new government program. A legislative analysis estimated the cost to be $400 billion per year. Half of the money for the system would come from existing state funds currently spent on healthcare, with the other half from new revenues such as a payroll tax, according to the analysis.

Newsom’s support of SB 562 has been nuanced. When he spoke at a convention of the California Nurses Assn., which endorsed Newsom and is the most vocal backer of the bill, he told the enthusiastic crowd, “It’s time to move 562.” But later, when talking with reporters, Newsom said he was referring to moving the bill through the legislative process, and acknowledged some “open-ended” issues still needed work.

When a coalition of labor unions, community health organizations and immigrant-rights groups tried to steer the health care debate away from SB 562 in March, proposing a series of measures to make healthcare in California more affordable and accessible, Newsom praised it as a “step in the right direction.” He said it had the potential to move California closer to universal coverage.

Villaraigosa and Chiang have accused Newsom of shifting his message on SB 562 to appease different audiences.

But Newsom has taken shots at them for playing both sides as well. Villaraigosa and Chiang say they support the concept of single payer — ideally at the national level — yet call Newsom fiscally reckless for supporting a California program. Newsom has insinuated that they lack the political courage to make it happen.

He also said the hand-wringing over the cost of single payer is an argument. “Most of the money needed to support a single-payer system already is being spent on the plans that it would replace, he said: government-run exchanges and private healthcare plans.

“I think we can achieve it. Let me tell you why: We’re already spending $367 billion a year on health insurance in the state of California,” Newsom said at a San Diego debate in February. “In every developed nation in the world that has a single-payer financing system, one thing is absolutely true: It costs less money than multi-player.”

U.S. healthcare tab to keep rising, led by higher costs for drugs and services, a government report says. Driven by rising prices for drugs and medical services, the nation’s healthcare tab will continue to outpace economic growth over the next decade, according to a new government report.

And by 2026, healthcare spending will account for almost one-fifth of the U.S. economy, an all-time record. The $367-billion figure Newsom used comes from a 2016 study done in part by Gerald Kominski, a professor of health policy at UCLA. Kominski agrees that, in theory, additional revenue might not be necessary if all of that money spent on healthcare in California can be funneled to a single state healthcare agency. Still, that would require permission from the Trump administration and Republican-led Congress — both hostile to Democratic leaders in California — to take control of Medicare and Medi-Cal funding Washington sends to the state, as well as convincing all Californians to switch to state-run healthcare coverage.

“There are still some significant barriers,” Kominski said. Micah Weinberg, president of the Bay Area Council Economic Institute, said Newsom fails to account for the increased costs of the comprehensive coverage being promised under a state single-payer system. Those costs include covering an estimated 1.8 million immigrant adults in California who are in the U.S. without authorization and covering long-term care not covered by Medicare, as well as eliminating all deductibles and other out-of-pocket expenses for Californians, he said.

“We’re being misled into believing that if you provide free universal care, it’s going to cost less,” Weinberg said.

Eastin, the only candidate of the four to throw her unequivocal support behind SB 562, has said implementing single payer is essential because “people are dying” for lack of proper healthcare. She has also acknowledged that it won’t be simple.

“What we have to do is have a conversation, an adult conversation, with real leaders at the table talking about how we’re going to close the gap and get additional money,” Eastin said at one of the Democratic debates, adding that she’s open to exploring different revenue sources, including a gross receipts tax.

The two top Republicans in the race, Rancho Santa Fe businessman John Cox, and Huntington Beach Assemblyman Travis Allen, have both ripped single payer as a government boondoggle.

Cox mockingly suggested that the state could also provide “single-payer food and single-payer housing” for everyone. Allen said it would be as efficient and customer-friendly as the DMV and bankrupt the state.

A 2017 poll by the nonpartisan Public Policy Institute of California found that 65% of adults in California favored the creation of a state single-payer healthcare program, but that support dropped to 42% when asked about paying higher taxes to fund it.

“You have to wonder, over time, whether this is an issue that candidates want to own,” PPIC President Mark Baldassare said.

Other states are having similar discussions regarding the single-payer system, whether it is Medicare for All or Medicaid for all or some other variety of a government-run system. But is the single-payer system the correct approach as I started reviewing last week?

“Medicare for all” is a popular idea, but for Americans, transitioning to such a system would be difficult, to say the least. Olga Khazan last year wrote that French women supposedly don’t get fat, and in the minds of many Americans, they also don’t get stuck with très gros medical bills. There’s long been a dream among some American progressives to truly live as the “Europeans1” do and have single-payer health care.

Republicans’ failure—so far—to repeal and replace Obamacare has breathed new life into the single-payer dream. In June, the majority of Americans told Pew that the government has the responsibility to ensure health coverage for everyone, and 33 percent say this should take the form of a single government program. The majority of Democrats, in that poll, supported single payer. A June poll from the Kaiser Family Foundation even found that a slim majority of all Americans favor single payer.

Liberal politicians are hearing them loud and clear. Vermont Senator Bernie Sanders reportedly plans to introduce a single-payer bill once Congress comes back from recess—even though no Senate Democrats voted for a single-payer amendment last month. Massachusetts Senator Elizabeth Warren has also said “the next step is single payer” when it comes to the Democrats’ health-care ambitions.

But should it be? It’s true that the current American health-care system suffers from serious problems. It’s too expensive, millions are still uninsured, and even insured people sometimes can’t afford to go to the doctor.

Single payer might be one way to fix that. But it could also bring with it some downsides—especially in the early years—that Americans who support the idea might not be fully aware of. And they are potentially big downsides.

First, it’s important to define what we mean by “single payer.” It could mean total socialized medicine, in that medical care is financed by—and doctors work for—the federal government. But there are also shades of gray, like a “Medicaid for all” system, where a single, national insurance program is available to all Americans, but care is rationed somewhat—not every drug and device is covered, and you have to jump through hoops to get experimental or pricier treatments. Or it could be “Medicare for all,” in which there’s still a single, national plan, but it’s more like an all-you-can-eat buffet. Like Medicare, this type of single-payer system would strain the federal budget, but it wouldn’t restrict the treatments people can get. Because it’s the term most often used in single-payer discussions, I’ll use that here.

The biggest problem with Medicare for all, according to Bob Laszewski, an insurance-industry analyst, is that Medicare pays doctors and hospitals substantially less than employer-based plans do.

“Now, call a hospital administrator and tell him that his reimbursement for all the employer-based insurance he gets now is going to be cut by 50 percent, and ask him what’s going to happen,” he said. “I think you can imagine—he’d go broke.” (As it happens, the American Hospital Association did not return a request for comment.)

The reason other countries have functional single-payer systems and we don’t, he says, is that they created them decades ago. Strict government controls have kept their health-care costs low since then, while we’ve allowed generous private insurance plans to drive up our health-care costs. The United Kingdom can insure everyone for relatively cheap because British providers just don’t charge as much for drugs and procedures.

Laszewski compares trying to rein in health-care costs by dramatically cutting payment rates to seeing a truck going 75 miles an hour suddenly slam on the brakes. The first 10 to 20 years after single payer, he predicts, “would be ugly as hell.” Hospitals would shut down, and waits for major procedures would extend from a few weeks to several months.

Craig Garthwaite, a professor at the Kellogg School of Management at Northwestern University, says “we would see a degradation in the customer-service side of health care.” People might have to wait longer to see a specialist, for example. He describes the luxurious-sounding hospital where his kids were born, a beautiful place with art in the lobby and private rooms. “That’s not what a single-payer hospital is going to look like,” he said. “But I think my kid could have been just as healthily born without wood paneling, probably.”

He cautions people to think about both the costs and benefits of single payer; it’s not a panacea. “There aren’t going to be free $100 bills on the sidewalk if we move to single payer,” he said.

He also predicts that, if single payer did bring drug costs down, there might be less venture-capital money chasing drug development, which might mean fewer blockbuster cures down the line. And yes, he added, “you would lose some hospitals for sure.”

Amitabh Chandra, the director of health policy research at Harvard University, doesn’t think it would be so bad if hospitals shut down—as long as they’re little-used, underperforming hospitals. Things like telemedicine or ambulatory surgical centers might replace hospital stays, he suspects. And longer waits might not, from an economist’s perspective, be the worst thing, either. That would be a way of rationing care, and we’re going to desperately need some sort of rationing. Otherwise “Medicare for all” would be very expensive and would probably necessitate a large tax increase. (A few years ago, Vermont’s plan for single payer fell apart because it was too costly.) Also, we have to go back even farther to see the experience in the great State of Massachusetts and their experience.

If the United States decided not to go that route, Chandra says, we would be looking at something more like “Medicaid for all.” Medicaid, the health-insurance program for the poor, is a much leaner program than Medicare. Not all doctors take it, and it limits the drugs and treatments its beneficiaries can get. This could work, in Chandra’s view, but many Americans would find it stingy compared to their employers’ ultra-luxe PPO plans. “Americans would say, ‘I like my super-generous, employer-provided insurance. Why did you take it away from me?’” he said.

Indeed, that’s the real hurdle to setting up single payer, says Tim Jost, emeritus professor at the Washington and Lee University School of Law. Between “80 to 85 percent of Americans are already covered by health insurance, and most of them are happy with what they’ve got.” It’s true that single payer would help extend coverage to those who are currently uninsured. But policymakers could already do that by simply expanding Medicaid or providing larger subsidies to low-income Americans.

Under single payer, employers would stop covering part of their employees’ insurance premiums, as they do now, and people would likely see their taxes rise. “As people started to see it, they would get scared,” Jost said. And that’s before you factor in how negatively Republican groups would likely paint single payer in TV ads and Congressional hearings. (Remember death panels?) It would just be a very hard sell to the American public.

“As someone who is very supportive of the Democratic Party,” Jost said, “I hope the Democrats don’t decide to jump off the cliff of embracing single payer.”

Common misconception: Not all European countries have single payer. But we all know that this is not true!! Those that have money can pay for private healthcare or travel to the U.S.A. for treatment.

More next week.

Remember, Father’s Day is coming up and our book is a great gift!!

“The Search for Excellence in Clinical Practice-A Handbook on Clinical Process Improvement for Providers” by Orsini and Gurny, published by Sentia Publishers.

I ended the last blog hinting about the losers in this new health care program and was encouraged to pursue this discussion while reviewing two articles.

But let me first set things straight, as a strategic planner, the reason we are where we are is due to the lack of real research and planning. As much as I am not a President Obama fan, I really believe he and years before, Hillary Clinton, really believed what they were proposing was a good thing for the American people. I only object to the method that was chosen and the politicization, the lack of real research and planning with people in the know.

I comments in this last paragraph were further strengthened when I read the comments by the Speaker of the House discussing the Republicans mistakes and the lack of ability to overturn the health care law and the need to modify it and make it work. It was interesting to read that House Speaker John Boehner inadvertently revealed that repealing Obamacare “isn’t the answer,” and that “Republicans also need to offer a replacement.”

I also object to Harry Reed and Nancy Pelosi being so arrogant and closed minded in not allowing a non partisan discussion and resolution of difficulties to result in a bill which can “get the job done” efficiently and effectively for all the American people.

This has become a political ping-pong ball and shows that our elected officials really don’t care about Middle America especially and also points to the necessity for term limits.

Jonathan Bernstein wrote that“ The challenge is that Obamacare is the law of the land. It is there and it has driven all types of changes on our health care delivery system. You can’t recreate an insurance market overnight…. So the biggest challenge we are going to have is—I do think at some point we’ll get there—is the transition of Obamacare back to a system that empowers patients and doctors to make choices that are good for their own health as opposed to doing what the government is dictating they should do.”

This is interesting to me due to one of my previous blogs and the strategy that needs to be embraced- getting over the repeal idea and instead find ways to make the law work.

Think about the question that I posed at the end of my last blog-Who are the Biggest Losers? Byron York in his latest Op-Ed piece notes that Obamacare losers are harder to discern. I think not! He finally noted that “The plans being offered through the exchanges in 2014 appear to have, in general, lower payment rates for providers, narrower networks of providers, and tighter management of their subscribers’ use of health care than employment-based plans do.” The Congressional Budget Office (CBO) said “These features allow insurers that offer plans through the exchanges to charge lower premiums (although they also make plans somewhat less attractive to potential enrollees).”

The health care analyst, Bob Laszewski, questions who is harmed and points out that “when carriers converted their old policies to Obamacare-compliant policies, it was typical for the insurance company to increase costs about 35%” and “That increase could come in the form of higher premiums, more co-pays and deductibles and narrower networks.” This is what we are seeing in that enrollees are facing higher premiums and higher deductibles, which add up to a total higher cost, as well as a narrower choice of hospitals, doctors and prescription drugs than they had before. Therefore, what we are finding is that health care is becoming a more expensive and troublesome system.

Rick Newman in his article in The Exchange (April 25, 2014) points out that there are three subsets of people whose policies were canceled and then are the posers under the Affordable Care Act (ACA): people who are self-employed, those over 35, those who are white, or some combination of all of these three.

The biggest losers to ACA are the people who lost their insurance coverage but are unlikely to qualify for subsidies through one of the exchanges, which require an income of less than $47,000 for an individual or $95,000 for a family of four. Some of these people who lost insurance coverage report paying twice as much with deductibles of $4,500-$7,500 or more. It was interesting that Mr. Newman pointed out that it so happens that these groups so impacted negatively tend to be Obama’s political opponents.

Do the insurance companies lose? In a previous blog I pointed out that WellPoint was planning to increase their premiums and now I read that CEO of Aetna, Mark Bertolini, stated that their premium increases would range from low single digit to double digits, based on its first quarter earnings. So the insurance companies never lose. The have to make a profit and usually the profit is much larger than the proposed profit margins that the committees and government departments are demanding for health care facilities.

Ethan Rome (The Truth About Health Insurance Company Profits: They’re Excessive) reviewed health insurance company profits and went on to further review the American trade group American Health Insurance Plan’s (AHIP) focus on profit margins which he thought was misleading when they quoted 4.4%, and designed to protect their massive income by shifting attention away from their return on equity — a key measure of profits as a percentage of the amount invested. “That return is a phenomenal 16.1% as of today. By that measure, health insurers are ranked fourth highest of the 16 industries in the health care sector. They also deliver a higher return for investors than cellphone companies, beer companies, mortgage companies, life insurance companies, TV broadcasters, drug store companies or grocery stores.”

In May 2011, the New York Times reported “the health insurance industry is enjoying record earnings while millions of Americans get less medical care. Wall Street investors are delighted with the industry’s profits, and to health insurance executives, that’s all that counts. Insurance CEOs want investors to buy their stock and keep share prices marching higher, and that’s exactly what has happened. To achieve excessive profits, insurers are happy to gouge consumers and small businesses, do little to rein in medical costs and spend billions of our premium dollars on lobbying, secret political activities, bloated executive pay and stock buybacks.”

How about the greedy doctors? Are they losers? In the beginning and for quite a while they will lose as they have for years as their reimbursements (what they are paid by the insurance companies and the government, i.e. Medicare and Medicaid) are further discounted. But they will not be able to keep their offices open unless they become employees of the hospitals, universities or convert to boutique type practices. The boutique practices will charge patient fees to become practice members and or start to do procedures that they are not trained for and for which the complication rate will be high. But the added income will be necessary to maintain their overhead expenses.

Having insurance policies that include $5,000- $7,500 deductibles means that almost all health care needs, office visits, tests and surgery will be out of pocket expenses. How does the new plan then encourage good health care behavior and encourage preventative care?

Yes, the uninsured, if they fulfill the requirements for the government subsidies, will get coverage, but who will take care of these patients and cane you change their “bad” behavior? Will we have enough doctors to provide care and what type of care will be provided? I will discuss these topics further in future blogs.

Let us also consider who is in control of the ACA and what their history predicts. These are the same government systems that have control of the problematic Medicare, Medicaid and Veteran health systems. Remember what we have been hearing about concerning the Veteran Administration Health Care problems in the last few weeks. Long waiting times, poor care, lack of care, deaths, suicides, etc. What then can we expect for the future control and management of the ACA?